Reperfusion Injury (RPI)/White Cord Syndrome (WCS) Due to Cervical Spine Surgery: A Diagnosis of Exclusion

Abstract

Background: Following acute cervical spinal cord decompression, a subset of patients may develop acute postoperative paralysis due to Reperfusion Injury (RPI)/White Cord Syndrome (WCS). Pathophysiologically, this occurs due to the immediate restoration of normal blood flow to previously markedly compressed, and under-perfused/ischemic cord tissues. On emergent postoperative MR scans, the classical findings for RPI/ WCS include new or expanded, and focal or diffuse intramedullary hyperintense cord signals consistent with edema/ischemia, swelling, and/or intrinsic hematoma. To confirm RPI/WCS, MR studies must exclude extrinsic cord pathology (e.g. extramedullary hematomas, new/residual compressive disease, new graft/vertebral fracture etc.) that may warrant additional cervical surgery to avoid permanent neurological sequelae. Methods: In the English literature (i.e. excluding 2 Japanese studies), 9 patients were identified with postoperative RPI/WCS following cervical surgical procedures. For 7 patients, new acute postoperative neurological deficits were appropriately attributed to MR-documented RPI/WCS syndromes (i.e. hyperintense cord signals). However, for 2 patients who neurologically worsened, MR studies demonstrated residual extrinsic disease (e.g. stenosis and OPLL) warranting additional surgery; therefore, these 2 patients did not meet the criteria for RPI/WCS. Results: The diagnosis of RPI/WCS is one of exclusion. It is critical to rule out residual extrinsic cord compression where secondary surgery may improve/resolve neurological deficits. Conclusions: Patients with acute postoperative neurological deficits following cervical spine surgery must undergo MR studies to rule out extrinsic cord pathology before being diagnosed with RPI/WCS. Notably, 2 of the 9 cases of RPI/WCS reported in the literature required additional surgery to address stenosis and OPLL, and therefore, did not have the RPI/WCS syndromes.

Cervical Spinal Cord Ischemic Reperfusion Injury: A Comprehensive Narrative Review of the Literature and Case Presentation

“…The Chin’s case was then followed up by multiple reported cases worldwide; all of them had the white cord sign appearing or enlarged on MRI postoperatively [ 2 ]. The term "white cord syndrome" appeared after excluding all causes that could result in such an event, including incomplete decompression of neuronal elements, instrumental failure, or compressing hematoma [ 3 ].…”

“…The same happened in a study by Page et al [ 4 ] and Hussein et al [ 11 ], as the patient developed neurological deficits 72 hours after the surgery. In the study by Epstein [ 3 ] and Giuseppe et al [ 5 ], cases developed somatosensory and motor-evoked potential loss during the closure of the fascia.…”

Medicolegal corner (spine): Contraindicated use of DuraSeal in anterior cervical spine led to quadriplegia

“…RPI/WCS is an extremely rare diagnosis attributed to an acute reperfusion of previously markedly compressed/ischemic spinal cord tissues [ Table 1 ]. [ 7 ] The classical MR findings include; “…new or expanded, and focal or diffuse intramedullary hyperintense cord signals consistent with edema/ischemia, swelling, and/or intrinsic hematoma.”[ 7 ] However, as a diagnosis of exclusion, it is only applicable to patients who develop new neurological deficits following cervical surgery where new/ residual extrinsic pathology responsible for and/or contributing to neural compromise have been excluded/ruled out. In this case, the “contraindicated” anterior cervical application of DuraSeal (i.e., to a confined space with an unrepaired CSF fistula) resulted in massive anterior cord compression, causing the patient’s quadriplegia [ Tables 1 and 2 ].…”

Misdiagnosis of “White Cord Syndrome” following posterior cervical surgery for ossification of the posterior longitudinal ligament: A case report

“…[4,5] WCS diagnosis of exclusion e diagnosis of WCS is one of exclusion; all other potential aetiologies of injury must first be ruled out. [2,3,7,8] In 2004, Seichi et al diagnosed WCS in 7 out of 114 patients following decompressive surgery; four had worsening of symptoms/ signs that never recovered, while three improved despite the expansion of an increased intrinsic cord signal on the postoperative MRI. [7] Vinodh et al in 2018 diagnosed the WCS in a patient with a C3 vertebral body metastatic tumor who postoperatively worsened, and failed to respond to highdose steroids.…”